Hyperplastic scars and keloids: part II: Surgical and non-surgical treatment modalities

Aberrant wound healing results in unsightly scarring, hypertrophic scarring, and keloid formation, causing functional and cosmetic deformities, discomfort, psychological stress, and patient dissatisfaction. Scar management, both surgical and non-surgical, continue to be important issues for the facial plastic surgeon. Many techniques for the management of hypertrophic scars and keloids have been proven through extensive use, but few are supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article presents an overview of the available therapies and provides recommendations for the treatment of abnormal scarring. The recommendations focus on the management of hypertrophic scars and keloids. Strategies for the management of keloids and hypertrophic scars are of continuing interest and studies are necessary to understand the basic mechanisms causing aberrant wound healing. In addition, an overview of new developments in molecular wound management and gene therapy, as they relate to facial plastic surgery, is provided.     

Hyperplastische Narben und Keloide

Aberrant wound healing results in unsightly scarring, hypertrophic scarring, and keloid formation, causing functional and cosmetic deformities, discomfort, psychological stress, and patient dissatisfaction. Scar prevention and management continue to be important issues for the facial plastic surgeon. This article presents an overview on the pathogenesis of a scar and of the different types of scars. Differences between keloids, hypertrophic scars and normal scars include distinct scar appearance, histologic morphology and cellular function in response to growth factors. Recent advances in our understanding of the wound healing process reveal possible causes for hypertrophic scars and keloids. This information might assist in the development of efficacious prevention and treatment for hypertrophic scar and keloid formation. This article also describes the strategies available for scar prevention. Recommendations focus on the management of hypertrophic scars and keloids.     

Hyperplastic scars and keloids. Part I: basics and prevention

Aberrant wound healing results in unsightly scarring, hypertrophic scarring, and keloid formation, causing functional and cosmetic deformities, discomfort, psychological stress, and patient dissatisfaction. Scar prevention and management continue to be important issues for the facial plastic surgeon. This article presents an overview on the pathogenesis of a scar and of the different types of scars. Differences between keloids, hypertrophic scars and normal scars include distinct scar appearance, histologic morphology and cellular function in response to growth factors. Recent advances in our understanding of the wound healing process reveal possible causes for hypertrophic scars and keloids. This information might assist in the development of efficacious prevention and treatment for hypertrophic scar and keloid formation. This article also describes the strategies available for scar prevention. Recommendations focus on the management of hypertrophic scars and keloids.     

Scar management: prevention and treatment strategies

PURPOSE OF REVIEW: Aberrant wound healing results in unsightly scar, hypertrophic scar, and keloid formation, causing functional and cosmetic deformities, discomfort, psychological stress, and patient dissatisfaction. Scar prevention and management, both surgical and nonsurgical, continue to be important issues for the otolaryngologist. RECENT FINDINGS: Both animal and human models continue to point to the integral role of transforming growth factor-beta in aberrant healing. Multiple extracts have promising results as therapies for scarring and are widely marketed but need to be further investigated. Scar prevention advancements include refinements in surgical technique, nutritional supplementation, and optimal wound care. Steroid injections continue to play a major role in the regression of scars and keloids. Dermatography assists in the minimization of scar appearance. Dermatography, laser therapies, intralesional 5-fluorouracil, and adjuvant radiotherapy are emerging therapies. Topical vitamin E utility is revisited. New surgical scar revision techniques include modified excision techniques and skin grafting. SUMMARY: Despite optimal efforts to avoid scar formation, aberrant wound healing may occur. The use of topical agents and intralesional steroid injections can minimize early scar formation. Strategies for prevention and management of keloids and hypertrophic scars continue to develop, as the basic science mechanisms underlying aberrant wound healing are elucidated.     

Mitomycin C in head and neck surgical procedures

Mitomycin C (MMC) is frequently used in combination chemotherapy. Its metabolites bind to DNA-molecules and causes DNA crosslinking, which interferes with the synthesis of DNA, RNA and proteins. MMC is thus able to reduce fibroblast proliferation. Moreover, MMC particularly inhibits the synthesis of extracellular matrix proteins including fibronectin and various collagens. These properties have been demonstrated in several experimental studies. Beside its merits in treatment of malignancies, MMC may thus be useful to prevent hypertrophic scars and keloids, adhesions and ostial restenosis following head and neck surgical procedures. Clinically, MMC has been applied to prevent scarring after ophthalmologic surgery. Recent experimental and clinical trials investigating the effects of MMC on wound healing following head and neck surgical procedures are reviewed.     

Management of the post-tracheostomy scar

Tracheostomy scar management is aimed at filling lost deep tissue bulk, the correction of tracheal skin tug, and a tension-free closure that falls more naturally into the neck folds. Three cases are used to illustrate the major principles involved in the correction of tracheostomy scars. Those reconstructive principles are 1) re-approximation of individual layers of the neck for improved contour and release of tracheal skin tug, 2) filling of tissue deficit, using scar de-epithelialization, muscle flaps, or acellular dermal grafts, 3) excision of hypertrophic scarring or keloids, and 4) horizontal wound closure using simple closure or local skin flaps such as z-plasty. The goals and techniques outlined can resolve skin adherence to the trachea and can improve scar appearance in this noticeable location.     

Myofibroblasts in head and neck surgery. An experimental and clinical study

Myofibroblasts in human granulation tissue have many of the structural and functional characteristics of smooth-muscle cells and appear to be responsible for wound contraction. They have also been identified in contracted scar tissue in nongranulation wounds. In this report, their role in head and neck wound healing will be explored utilizing transmission electron microscopy and immunoperoxidase techniques with antibodies to the intermediate filament vimentin and to muscle-restricted actins. In piglets, high-tension, low-tension, and granulating wounds were created and studied with serial biopsy specimens. Results showed few myofibroblasts in either the high- or low-tension wounds and multiple myofibroblasts in the granulating wounds. In the clinical studies, the immunoperoxidase technique with monoclonal antibody to muscle-specific actins proved most useful in identifying myofibroblasts. Myofibroblasts were present in granulating wounds and hypertrophic scars. They were not widely present in mature keloids.     

Expression of urokinase-type plasminogen activator and its receptor in keloids

BACKGROUND: The urokinase-mediated plasminogen activation (uPA) system plays a central role in a number of cellular processes including tissue remodeling, cell migration, and angiogenesis. Elevated uPA activity has also been seen with tumor invasion and metastasis in a variety of malignancies. Keloids represent an aberrant form of wound healing characterized by uncontrolled growth with invasion beyond the margins of the original wound. The regulation of this cellular process remains poorly understood. We hypothesize that keloids will have increased staining percentage for uPA and its receptor (uPAR) compared with normal scars. To our knowledge, no previous studies have examined the relationship of uPAR in keloid formation. DESIGN: Analysis of uPAR expression by immunohistochemistry in paraffin sections from 20 keloids and 18 normal scars. Expression was graded by a dermatopathologist according to percentage of cells staining for uPAR. SETTING: University Medical Center (Division of Otolaryngology-Head and Neck Surgery) and the Department of Dermatology at the University of Rochester Medical and Dental School, Rochester, NY. RESULTS: Of the 20 keloids, 8 (40%) strongly expressed uPAR (>50% of cells), while only 4 (22%) of 18 normal scars had similar staining. More than half of the normal scars stained minimally for uPAR (<5% staining). There was a strong expression of uPAR in the extracellular matrix in 14 (70%) of the 20 keloids, while no scar showed uPAR in the extracellular matrix. CONCLUSION: Our observation suggests that the uPA system is involved in the expansion of keloids beyond the wound margins in part through the degradation of the extracellular matrix, a finding that is supported by the strong expression of uPAR in the extracellular matrix and collagenous cords in most keloids studied.     

Dermabrasion in facial surgery

Surgical planing or dermabrasion has many uses in facial aesthetic and reconstructive surgery but often is an underutilized technique. The purpose of this paper is to familiarize the head and neck and facial plastic surgeon with some of these uses extending from trauma to rejuvenation of the aging face. Detail will be presented regarding analysis for conditions where dermabrasion is indicated and in dealing with modifications of surgical technique. The author feels that dermabrasion is the treatment of choice for scars and acne and favors it over chemabrasion or chemical peel even for fine rhytids because the depth of dermabrasion can be precisely controlled and varied according to the location of and the degree of scarring or facial wrinkles. It offers early and predictable healing without concern for the penetration and absorption of chemical elements (especially phenol). Dermabrasion may be combined with other procedures such as scar revisions, dermal shaves, and de-epithelization of flaps.     

Bioinhibition of human fibroblast cultures sensitized to Q-switch II dye and treated with the Nd: YAG laser: a new technique of photodynamic therapy with lasers

Kodak Q-switch II dye has recently proven to be an effective biostimulative agent on normal human fibroblast cultures. The potential for this dye as a new chemosensitizing agent for the treatment of connective tissue diseases and wound healing with the Nd:YAG laser was examined. Two normal fibroblast cell lines were first sensitized to a nontoxic dose of Q-switch II dye, then subjected to treatment with an Nd:YAG laser at 1,060 nm, with varying levels of energy and temperatures determined by a reproducible method of dosimetry. The results indicate that Q-switch II dye at nontoxic doses of 0.1 micrograms/ml enhances the cytotoxic effects of the Nd:YAG laser at temperatures as low as 36 degrees C. Furthermore, at physiological temperature ranges as low as 24 degrees C to 34 degrees C, cell duplication was inhibited, but cell viability was not affected. Similar results were not observed when fibroblast cultures were treated with the laser alone. These observations suggest that Q-switch II dye is an effective chemosensitizing agent for the Nd:YAG laser and could potentially be used to reduce collagen deposits in conditions such as keloids and hypertrophic scars.     

Plastische Deckung von Weichteildefekten im Gesicht

The difficulties in facial reconstruction derive from the unique character of the face and the availability of local matching tissues. Facial reconstructive surgery must aim at a functionally and aesthetically rehabilitated patient. The performance of facial plastic surgery requires an understanding and the application of many important principles. The aim of this paper is to review the critical factors to be considered in the management of surgical wounds by second-intention healing, primary closure, skin grafting, and repair with local or distant free flaps. The key concepts useful in flap choice and implementation are discussed. In addition, an overview of new developments in tissue engineering and gene therapy as they relate to facial plastic surgery is provided.     

Camouflaging scars in the head and neck area.

Any break in the continiuty of healthy skin results in the formation of a scar. The way the scar is formed and the factors affecting the final appearance are discussed. Basic surgical principles as they relate to the revision of scars and the different surgical techniques used for revising scars are presented. Surgical adjuncts used following scar revision and hypertrophic scars and keloids and their treatment are also discussed.     

Die Behandlung komplexer Narben im Gesicht

Correction of complex facial scars frequently requires individualized, multimodal strategies, which are composed of various therapeutic measures. This report provides information on techniques for correction of contractures, atrophic scars, scars within hair-bearing regions of the face and auricular keloids. Additionally, we present adjuvant procedures in a subject-related manner.     

Combined modalities in the management of hypertrophic scars and keloids.

A surgeon has many treatment options available during the longterm management of a patient with keloids or hypertrophic scars. The thoughtful combination of multiple modalities in a staged manner may produce a more favorable result than the application of a single technique. A case is presented which illustrates the concept of preliminary treatment with cryotherapy and low dose intralesional triamcinolone followed at interval by surgical excision.     

Management of lacerations and scars.

The purpose of this paper is to review and update the subject of management of scars and lacerations. The surgion who accepts responsibility for management of soft tissue injuries must be aware of fundamental surgical principles as well as detailed technique. Knowledge of basic anatomy and wound physiology is utilized and applied. Emphasis is placed on management of the total pateint. The specialist must accept the role of team captain and establish an order of priority in management and in wound analysis. By having a basic knowledge of wound healing and the lines of favorable contracture, one is better able to prognosticate the eventual healing of the wound after proper management. By being able to predict wound contracture and scar maturation, the patient can be better informed as to what to expect during the period of healing. With lacerations immediate repair is carried out. With scars there is more time for planning and photographic analysis. The contracting forces will by this time have identified themselves and the degree of release of the contracture or camouflage can be determined. Specific wound management emphasized meticulous closure in layers and the use of skin hooks with the interrupted subcuticular suture. Skin sutures with both the continuous subcuticular suture and interrupted sutures of monofilament nylon using the spring-loop are described. Emphasis is placed on the preparation of the skin margins with slight beveling of the skin edges and undermining with precise even thickness of the skin especially at the wound margin. For scar revisions a minimum time of six months should elapse, and 12-18 months is better. Complications include infection, hematoma, wound separation, and rejection of suture materials. Keloids are discussed briefly, particularly regarding the use of intralesional injection steroids. Broken line camouflage techniques are discussed with the regard to breaking up contracture without lengthening. Lengthening either existing or anticipated contractures is accomplished with Z-plasty. The multiple Z-plasty, W-plasty, and Zig-Zag plasty are aimed towards creating a less conspicuous scar and creating some diffusion of the forces of contracture. A technique for a "practical Z-plasty" is described. Both free grafts and skin flaps sometimes must be utilized to fill tissue defects and break up line of contracture. The materials presented and conclusions drawn are based on 25 years of active emergency room coverage and long term follow-up of treated patients. It is the responsibility of the physician to act within the first few hours and to take the time necessary for accurate approximation and realignment of both soft tissue and bone injuries. Minimal scarring depends on accurate approximation of skin margins without tension. The need for early meticulous repair, so that unsightly scars and disfigurements may be prevented, cannot be overemphasized.     

Auricular keloids: treatment and results

The aim of this study was to present long-term results in patients with auricular keloids after surgical excision and/or medical therapy by corticoid injection. A retrospective study at an academic tertiary referral centre is presented. Seventeen patients after excision, injection of corticoid, full skin grafting (single therapy or combination of interventions) for auricular keloids were followed up. The validated questionnaires SF-36 and patient outcomes of surgery-head/neck were applied to evaluate the quality of life and the patients’ satisfaction after therapy. Photographs of the former keloid site were rated by an experienced facial plastic surgeon being unaware of treatment method and the patient’s own estimation. The best results for retroauricular keloids were reached by excision, skin grafting and triamcinolone injection, and for earlobe keloids by excision, primary wound closure and triamcinolone injection. Both in rating by the patients and in grading by an investigator, the highest scores for aesthetics and satisfaction were found after triamcinolone injection together with or without excision or skin grafting. A size-related resection of keloids with defect reconstruction by full thickness skin grafting for retroauricular keloids and primary wound closure of ear lobe keloids with an additional steroid injection lead to good cosmetic results and high level of satisfaction among patients.     

Concepts of soft-tissue trauma repair

The proper evaluation and treatment of soft-tissue trauma to the face is extremely important because of the psychologic, cosmetic, and functional sequelae that can occur from these injuries. The facial trauma surgeon should have a wide armamentarium of techniques to manage soft-tissue facial trauma and should approach the repair in a meticulous and scientific fashion. Although the best possible repair of the acute trauma is the goal, it is usually necessary to perform later some camouflage or revision procedures on the scar because of the high likelihood of hypertrophic scarring or inappropriate healing in the trauma scar.     

Carbon dioxide laser excision of earlobe keloids. A prospective study and critical analysis of existing data

When steroid injections have failed, the most common approach for the treatment of earlobe keloids is surgical excision. The carbon dioxide laser has recently been used with varying reported success in the treatment of keloids and hypertrophic scars. Proponents of this technique claim that the intrinsic properties of laser surgery, which slows fibroblast proliferation, may be responsible for delaying or preventing the recurrence of keloids. We report results on the effectiveness of carbon dioxide laser excision of earlobe keloids. Eighteen patients were followed up from 8 months to 2 years, or up to a recurrence. Four patients within this group with bilateral keloids provided a self-controlled sample. One ear was randomly chosen for laser excision and the other for scalpel excision. There were recurrences in both groups. There were also 17 recurrences in a group of 23 keloids excised by laser, 9 occurring between 6 and 12 months postoperatively. We failed to demonstrate a lower recurrence rate of earlobe keloids using the carbon dioxide laser and discuss some of the factors responsible for this outcome.     

Kontrollierte Feinstdermablation im Gesichtsbereich mit dem Erbium:YAG-Laser

The erbium: YAG laser (wavelength 2940 nm; pulse duration 0.350 ms; pulse energy 0.1-1.7 J) allows vaporization of very thin skin layers without scarring and minimal lateral thermal injury due to an extremely short pulse duration. It permits exact ablation of relatively large areas of facial skin. We report our results with 216 patients following treatment for different facial lesions (facial wrinkles, acne scars, syringomas, and circumscribed sebaceous gland hyperplasia) using a new erbium: YAG laser system. Good-to-excellent cosmetic results were obtained in these patients. Our findings show that the erbium: YAG laser is an elegant and promising new method for the treatment of facial lesions.     

Secondary intention healing. The primary approach for management of selected wounds

Secondary intention healing is an ancient and well-established method of wound management. Since the advent of various reconstructive techniques, it is often forgotten as a valuable alternative to immediate surgical reconstruction of wounds. In certain situations the cosmetic and functional results of secondary intention healing are equal to the results of more complex reconstructive surgery. We describe a case in which remarkable results were obtained from spontaneous healing of a facial wound.